Late results with bioprosthetic valves in the elderly.

AIM: We report the long-term outcome of aortic and mitral bioprostheses in patients over 65 years of age at the time of implantation. The aim was to determine actuarial patient survival, causes of death, and the rate of documented primary structural deterioration. METHODS: One hundred ten patients > or = 65 years of age (mean, 73.4; range, 65-82) underwent successful bioprosthetic valve replacement (aortic, n = 71; mitral, n = 32; both, n = 7) from 1979 to 1985. The valve was pericardial in 39 cases and porcine in 78. The mean follow-up was 8.5 years (101.9 months-total; 934 patient-years; range, 2 months to 15 years). RESULTS: Actuarial patient survival was 79.6% (71-86) at 5 years and 62.4% (52-71) at 10 years. Forty-four patients died, 21 from valve-related causes and 23 from other causes. Thirteen patients (11.8%) had reoperation for valve-related complications: 10 structural deteriorations, 2 paravalvular leaks, and 1 case of endocarditis. One surgical death occurred (7.7%). Twenty-six percent of the patients were receiving anticoagulants because of atrial fibrillation, and 6.4% developed severe bleeding (2.9% patient-years). CONCLUSIONS: Long-term follow-up of these patients > 65 years of age, undergoing bioprosthetic value replacement surgery revealed a low rate of documented primary structural deterioration (0.95% per patient-year), a low mortality rate on reoperation (7.7%), and a high mortality rate due to non-value-related causes (52.3%).

Late coronary angioplasty and ventricular late potentials.

To assess the effect of successful late coronary angioplasty of an occluded infarct-related artery on the prevalence of ventricular late potentials, signal-averaged electrocardiograms were recorded in 123 consecutive patients surviving a first acute myocardial infarction (58 with and 65 without mechanical reperfusion of the occluded coronary artery). Multivariate analysis showed that successful reperfusion by late angioplasty of the infarct artery contributes to a decrease in the prevalence of late potentials.

Relation between successful late coronary angioplasty of an occluded, infarction-related artery and lower prevalence of ventricular late potentials.

BACKGROUND: The effect of mechanical reperfusion of the infarction-related artery on ventricular late potentials (VLP) continues to be debated. OBJECTIVE: To assess the influence of successful late coronary angioplasty on the prevalence of VLP after acute myocardial infarction (AMI). METHODS: We studied 113 consecutive patients (97 men, 16 women, mean age 57 +/- 10.8 years) in whom the infarction-related artery was occluded (thrombolysis in myocardial infarction score 0 or 1) at the time of the initial coronary arteriography 10.9 +/- 6.4 days after a first AMI. Successful late angioplasty of the infarcted artery was performed in 55 patients a mean of 11.5 +/- 7.2 days after AMI. The remaining 58 patients received a conservative treatment. Signal-averaged electrocardiograms (SAECGs) were recorded 25 +/- 10.2 days after AMI. Multivariate analysis was undertaken to assess the influence of late coronary angioplasty with respect to age, sex, infarction site, angiographic ejection fraction, extent of diseased coronary arteries, thrombolysis and time of recording the SAECG. RESULTS: The overall prevalence of VLP was 27%. It was greater in patients without than in those with angioplasty (40% compared with 15%, P = 0.017). Multivariate analysis demonstrated that successful angioplasty (odds ratio 3.2; P = 0.019) and ejection fraction >0.4 (odds ratio 5.1; P = 0.0051) were the strongest independent predictors of an absence of VLP. 'Non-inferior' myocardial infarction was also correlated with the absence of VLP (odds ratio 2.6), but with borderline significance (P = 0.053). CONCLUSION: When performed in an occluded, infarction-related artery, successful late coronary angioplasty contributes to a significant decrease in the prevalence of VLP.

[Factors determining the improvement of effort capacity in aged patients with coronary disease during the 1st month following coronary surgery]. / Facteurs déterminant l'amélioration de la capacité à l'effort des coronariens âgés dans le premier mois suivant la chirurgie coronaire.

UNLABELLED: In order to determine the predictive factors of improvement of the physical capacity of elderly coronary patients following coronary surgery, we retrospectively analysed the data of 204 consecutive patients over the age of 65 years (181 men, 23 women, mean age: 70 +/- 4.4 years), admitted for a phase II active training programme. METHODS: The patients were divided into two groups as a function of the rate of improvement of the duration of the stress test: group A (improvement greater than or equal to 25%; n = 108) and group B (less than 25%; n = 96). Comparison of these 2 groups by multivariate analysis identified predictive factors of improvement among seven variables: age, sex, excess weight, haemoglobin, number of training sessions, duration of baseline stress test, interval between bypass graft and start of training. RESULTS: After training, the duration of the stress test and the maximal power were improved by 26.5% and 24%, respectively: 7.1 +/- 1.7 vs 8.9 +/- 2.3 minutes (p = 0.0001); 79 +/- 18.4 vs 97.8 +/- 23.7 watts (p = 0.0001). 34 (1.4%) of the 2,396 training sessions were temporarily interrupted, because of muscle fatigue in 47% of cases. Patients who had readapted before the 15th postoperative day presented fewer incidents: 4.3% vs 13.1%; NS. Only three variables appeared to be predictive of improvement of physical capacity: a duration less than 6 minutes on the baseline stress test (p = 0.0003), more than 12 training sessions (p = 0.0029) and age less than or equal to 70 years (p = 0.014). CONCLUSION: In elderly subjects undergoing coronary surgery, the improvement of physical capacity is greater the lower the baseline effort, the lower the age-group and the greater the number of training sessions. In the absence of contraindication, it appears justified to include elderly coronary patients in training programmes, even when their baseline effort level appears to be low. This training can be started by the 15th postoperative day.

[Rehabilitation of aged patients with bicycle ergometer after coronary surgery]. / Réadaptation des patients âgés sur cyclo-ergomètre au décours de la chirurgie coronaire.

This study was undertaken to assess the contraindications to rehabilitation by exercise testing on a bicycle ergometer and the tolerance of this procedure in elderly patients recovering from coronary surgery. One hundred and eighty-four patients aged over 65 years were included (Group I). The rehabilitation program consisted of exercise testing on admission period. The results were compared with those of 146 patients aged 65 or less (Group II). Twenty-six per cent of the elderly patients had a contraindications to this type of rehabilitation compared with only 4.8% in Group II. The main contraindications were extracardiac (21.7%), including infectious causes (4.3%), neuropsychiatric (3.3%), respiratory (2.7%) and rheumatological conditions (2.2%). Cardiac causes represented only 4.3% of the contraindications. In the patients undergoing the training program, the maximum power and the duration of exercise testing increased respectively from 81 +/- 17 to 97 +/- 21 watts (+21% ; p < 10(-3)) and 7 +/- 1.7 to 9 +/- 2 minutes (+28.6%, p < 10(-3)). The change in these parameters was comparable in the other group: 94.5+/- to 118 +/- 26 watts (+24.8% ; p < 10(-3)) and 8.5 +/- 1.9 to 10.9 +/- 2.4 minutes (+28.2% ; p < 10(-3)). On the other hand, the rate-pressure product decreased slightly in the elderly patients (-5.5% ; p = 0.07, compared with -13% in Group II, p = 0.001). Complications were rare: 1.6% of temporary interruption of a session (versus 0.6%). No serious complications were observed. The authors conclude that, after coronary surgery, the majority of elderly coronary patients can participate in physical training programs on bicycle ergometers without major complications. In the absence of contraindications, patients, and even elderly patients, should be encouraged to enroll for these programs after coronary bypass surgery.

[Influence of post-infarction myocardial revascularization on the prevalence of delayed potentials]. / Influence de la revascularisation myocardique après infarctus sur l'incidence des potentiels tardifs.

It has been shown that the presence of ventricular late potentials is a predictive factor of ventricular tachycardia and sudden death after myocardial infarction. The value of thrombolysis in the reduction of the prevalence of ventricular late potentials is now well established. However, the effects of other modes of revascularisation is less well known and more controversial. The authors undertook a retrospective study of 139 consecutive patients undergoing coronary angiography after primary myocardial infarction. The presence of ventricular late potentials fulfilling two of the three usual criteria was sought after a revascularisation procedure. The overall prevalence of ventricular late potentials was 30.9%. This was not affected either by the site of infarction of by the single or multiple character of the coronary artery disease. In addition, the left ventricular ejection fraction was not significantly different in patients with positive ventricular late potentials compared with the others. On the other hand, revascularisation of the culprit lesion responsible for the infarction was strongly correlated with a lower incidence of ventricular late potentials (p < 10 (-5)). In particular, the different incidence of positive late potentials between the dilated (9.3%) and non-dilated group (49.2%) was statistically significant (p < 10 (-6)) without any correlation to the single or multiple character of the coronary disease. The authors discuss the different reports in the literature concerning the effects of angioplasty and coronary bypass surgery on the incidence of ventricular late potentials. Conclusion; the review of the literature shows that thrombolysis significantly reduces the incidence of late potentials after myocardial infarction and the present study suggests that angioplasty and coronary bypass surgery may also be effective.

Bioprosthetic valve replacement in the elderly.

One hundred and ten patients aged more than 65 years (mean, 73.4; range, 65-82) underwent successful bioprosthetic valve replacement (aortic, n = 71; mitral, n = 32; both, n = 7) from 1979 to 1985. The valve was pericardial in 39 cases and porcine in 78. The mean follow-up was 75 months (total, 688 patient-years; range, 2 months to 12 years). Actuarial patient survival was 79.4% at 5 years and 55.2% at 10 years. Thirty-seven patients died: 18 from valve-related causes and 19 from other causes. Eight patients have been reoperated on for valve-related complications (1.17% per patient-year): five primary deteriorations, two paravalvular leaks and one case of endocarditis. One surgical death occurred (12.5%). Twenty-five percent of the patients were receiving anticoagulants because of atrial fibrillation, and 5.4% developed severe bleeding (3.8% patient-year). Mid-term follow-up of these patients aged more than 65 years and undergoing bioprosthetic valve replacement surgery revealed a low rate of documented primary structural deterioration (0.9% per patient-year), a low mortality rate on reoperation (12.5%) and a high mortality rate due to non valve-related causes (51.4%).

[Surgical mitral valvuloplasty in the treatment of mitral valve diseases]. / La place de la plastie mitrale chirurgicale dans le traitement des maladies de l'orifice mitral.

Mitral valve repair surgery, in presence of a pure mitral leakage or one associated to a stenosis, is not only possible but has been well codified for a decade. According to damage, there are two methods of operation: valvular mobilization surgery and valvular motion amplitude reduction surgery. They are usually associated to annuloplasty with a Carpentier prosthetic ring. The incidence of late mortality is of 0.6 p. 100 pt/yr, that is to say 91.7 p. 100 at 13 years. This late survival rate is about 20 p. 100 better than for a valvular replacement. Reoperations rate is 1.6 p. 100 pt/yr. The incidence of thromboembolic event occurrence is low: 0.5 p. 100 pt/yr. The ideal indications for mitral valve repair are represented by damage of prolapse from a degenerative origin for which results are better and more constant. For rheumatic damage, the valvular repair indication depend on the valvular tissue elasticity and area. The presence of calcification and extensive fibrosis remain on principle counter-indications.